Midwives as gatekeepers to a restricted service
I was getting my hair cut this morning, listening to my hairdresser describe her positive outlook
on birth. She gave birth four times. As she told her stories and made me laugh, I heard other layers to her accounts of straightforward but somewhat precipitate births, that were all too familiar to me. She recalled how, when she arrived at her local maternity unit feeling her fourth baby’s head descending, she was greeted with sceptical remarks and derision. ‘How could she know?’ This passing reference was almost lost in the telling of her stories, however they resonated and reaffirmed the findings from my study ‘Are you Listening to me?’ (Shallow, Deery & Kirkham 2017).
During the study I held in-depth interviews with thirteen mothers who all either arrived very late in labour or who gave birth unexpectedly out of hospital, having been told by midwives that they were not (yet) in labour. Some were turned away and sent home on more than one occasion. I will never forget Jan who described vomiting on the grass verge beside the graveyard on her way home after two prior admissions. These women had not planned to give birth at home, they had believed the narrative that hospital is the safest place to birth their babies. Here is what Jan had to say:
‘I ended up petrified with both of them. You’re looked after throughout your pregnancy, you’re made to feel really special, you’re made to feel, you know you get a headache “you must phone up in case it’s pre-eclampsia”, anything when you’re pregnant, you know it’s so precious, the baby’s so precious. Why when you are in labour does no one give a shit? No one cares about you, you’re just an inconvenience until you get to 4cm and then you’re fine but if you’re 0 to 4 you’re a massive pain in the bum to everybody. Why is it like that? It’s atrocious really’. (Jan 2014)
As a result, giving birth without support or last-minute births just after arrival at the hospital, were traumatic and deeply upsetting for women (see Shallow 2019). All these mothers had what is called a ‘normal birth’ or ‘normal delivery’. However, ‘there was nothing normal about it’ (Fran 2014)
To get a more general view I held a series of focus groups with both mothers and midwives to determine how widespread was the practice of turning mothers away when they presented to midwives seeking support in labour. From their very different perspectives I found that it was routine to send mothers home and deny admission if a woman’s cervix was less than 4 centimetres dilated, irrespective of whether or not a woman was happy to go home or not. A quick google search will reveal a multitude of similar accounts of women who have given birth in nearby hotels, or in the car park or even on the pavement in the street in their rush to return to the hospital after being sent home. I wanted to know what was going on.
In summary, I found that many women are told they are ‘not in labour’ when they know otherwise, and admission to hospital to give birth is deferred. For some women, who report significant pain, this results in repeated pre-admissions, which increases their anxiety and distress. Some women stay at home or go home reluctantly and return to the maternity unit in advanced labour, and some women do not make it back to the hospital in time and give birth unexpectedly out of hospital.
The main aim of my study was to explore these issues and raise awareness about a gap in service provision. I chose a research method (Feminist Participatory Action Research FPAR), for its collaborative confidence-building potential. I wanted to work with mothers and midwives, and so, after the series of separate interviews and focus groups, we came together to validate and discuss preliminary findings in a one-day workshop. This had not been done before.
Summary of research findings
After decades of scaremongering about childbirth, many women lack confidence in their own potential and seek professional guidance and support at this time. Caught in this dependency model are women who know they are in labour and are inappropriately sent home based on the 4cm rule. It is these women who either arrive late in labour or who birth unintentionally at home, who are denied the pain relief and the fetal monitoring that they had been assured of throughout pregnancy and this is a safety issue.
Compounding this situation are rapid changes in service provision. Changes that women are not prepared for; such as shorter hospital stays due to shortage of beds, staff and hospital closures. As a result, midwives find themselves acting as organisational gatekeepers to a restricted service rather than focusing on the expressed needs of women. They are reluctant to involve women in decision- making for fear of being overwhelmed.
The policy to encourage women to stay at home for as long as possible without midwifery support is flawed and increases risks to women. Burgeoning reactionary check lists combined with restricted capacity, stifles mother-midwife interactions and leads to inappropriate decision-making.
Women’s subjective experiences of labour did not accord with the midwives’ objective diagnosis of labour. This conflict resulted in women burying their own feelings, deferring instead to professional knowledge and this caused them conflict both in labour and for some time afterwards.
The conflicts between mothers and midwives and between groups of midwives themselves who described ‘becoming other’ caused behavioural changes in midwives in order for them to be able to adapt and cope (see Shallow 2018).
Appearing uncaring, was not how midwives wished to be. Processing mothers, whilst at the same time gatekeeping admissions, has serious implications for the integrity of midwifery as a caring profession in general, and as a safe profession within the context of midwifery-led care in midwifery units/birth centres, as well as in obstetric labour wards.
Actions from my study have so far centred on raising awareness about a gap in service provision and to expose how overall maternity service provision is affected by political influences, which have resulted in marginalising and disabling both childbearing mothers and NHS midwives. We cannot fix maternity care until we understand what is undermining it.
The women and midwives in this study adopted a pragmatic approach and based their recommendations on what is and not how it could be. Had continuity of carer been the norm, arguably we would not have the problems this study identified, because women could confidently ring their midwife when they needed support, coaching or advice.
With that in mind, the women and midwife participants made and prioritised the following [verbatim] recommendations:
· See at home for early assessment – for reassurance and confidence building
· More midwives are needed - to enable midwives to take time when interacting with women
· Enable women to stay in – when they are in the ‘so called’ latent phase of labour
· Keep initial contact ongoing i.e. a hot line with dedicated midwives, who can maintain negotiated, continued contact up until admission
· Free, and accessible, antenatal education for all pregnant women
· Trust in women’s and midwives’ intuition
· Stop NOT involving women in decision-making
· Stop using negative terminology- i.e ‘you are not in labour’, ‘you are only’ [0-4] centimetres
So my key message to midwives, Heads of Midwifery and policy makers is:
Labour is what a woman says it is, she owns it.
When women are involved in decision-making and time is released for midwives to interact meaningfully, and preferably in a continuity of care model, women’s self-confidence is increased, and satisfaction and safety are enhanced. This finding is significant, and it matters.
Shallow, H. Deery, R. & Kirkham, M. (2017) Exploring midwives’ interactions when labour begins: A study using Participatory Action Research Midwifery no 58, pp 64-70.
Shallow, H. (2018) When Midwives Become Other In Untangling the Maternity Crisis Edwards, Mander & Murphy Lawless (eds) Routledge Publications Chapter 8.
Shallow, H. (2019) Getting it Right First Time In Understanding Anxiety, Worry and Fear in Childbirth Kathryn Gutteridge (Editor) Springer publications.